# Fluticasone- vs Budesonide-Based Dual Therapy for COPD

## TL;DR

A study found that a specific dry powder inhaler for COPD slightly reduces the risk of severe flare-ups compared to other inhalers, while also being more environmentally friendly.

## Contribution

This study reveals clinically relevant differences between dry powder and metered-dose ICS-LABA inhalers in COPD outcomes.

## Key findings

- Fluticasone furoate–vilanterol dry powder inhalers reduced COPD exacerbation risk by 9% vs budesonide-formoterol metered-dose inhalers.
- Fluticasone furoate–vilanterol also showed a 6% lower exacerbation risk compared to fluticasone propionate–salmeterol dry powder inhalers.
- No significant differences in pneumonia hospitalization risk were found across the three inhaler types.

## Abstract

Are different inhaled corticosteroid (ICS)–long-acting β-agonist (LABA) inhalers associated with different clinical outcomes among patients with chronic obstructive pulmonary disease (COPD)?

In this cohort study of new ICS-LABA users, the dry powder inhaler fluticasone furoate–vilanterol was associated with a 9% lower risk of first moderate or severe COPD exacerbation compared with the metered-dose inhaler budesonide-formoterol and a 6% lower risk compared with the dry powder inhaler fluticasone propionate–salmeterol. Fluticasone propionate–salmeterol and budesonide-formoterol were associated with clinical outcomes that were similar to one another.

These findings suggest that dry powder fluticasone-containing ICS-LABAs, which generate less than one-twentieth the greenhouse gas emissions of metered-dose formulations, have similar or slightly improved clinical outcomes compared with budesonide-formoterol among new users with COPD.

This cohort study compares chronic obstructive pulmonary disease (COPD) exacerbations and pneumonia hospitalizations among adults receiving fluticasone furoate–vilanterol dry powder inhalers, fluticasone propionate–salmeterol dry powder inhalers, and budesonide-formoterol metered-dose inhalers for COPD.

Inhaled corticosteroid (ICS)–long-acting β-agonist (LABA) inhalers are generally considered therapeutically equivalent when treating chronic obstructive pulmonary disease (COPD). However, metered-dose inhalers in the class are associated with substantially higher greenhouse gas emissions than dry powder formulations, and studies have raised questions about potential intraclass differences in clinical outcomes among patients receiving ICS-LABAs.

To analyze COPD exacerbations and pneumonia hospitalizations associated with once-daily fluticasone furoate–vilanterol dry powder inhalers, twice-daily fluticasone propionate–salmeterol dry powder inhalers, and twice-daily budesonide-formoterol metered-dose inhalers in adults with COPD.

This cohort study was conducted using longitudinal commercial claims data of US adults aged 40 years or older with COPD. Patients were 1:1 pairwise propensity score matched into 3 cohorts: (1) new users receiving fluticasone furoate–vilanterol vs budesonide-formoterol between January 1, 2014, and February 29, 2024; (2) new users receiving fluticasone furoate–vilanterol vs fluticasone propionate–salmeterol between January 1, 2014, and February 29, 2024; and (3) new users receiving fluticasone propionate–salmeterol vs budesonide-formoterol between January 1, 2007, and February 29, 2024.

Receipt of a once-daily fluticasone furoate–vilanterol dry powder inhaler (Breo Ellipta; GSK), twice-daily fluticasone propionate–salmeterol dry powder inhaler (Advair Diskus; GSK), or twice-daily budesonide-formoterol metered-dose inhaler (Symbicort; AstraZeneca).

The primary outcomes were first moderate or severe COPD exacerbation and first pneumonia hospitalization. Hazard ratios and 95% CIs were estimated using Cox proportional hazards regression models.

The cohorts included 38 070 matched pairs of patients receiving fluticasone furoate–vilanterol vs budesonide-formoterol (58.8% women; mean [SD] age, 71.0 [9.0] years), 20 471 matched pairs of patients receiving fluticasone furoate–vilanterol vs fluticasone propionate–salmeterol (58.3% women; mean [SD] age, 69.9 [9.2] years), and 55 627 matched pairs of patients receiving fluticasone propionate–salmeterol vs budesonide-formoterol (56.2% women; mean [SD] age, 68.3 [9.0] years). Patients receiving fluticasone furoate–vilanterol had a 9% lower risk of moderate or severe COPD exacerbations compared with those receiving budesonide-formoterol (hazard ratio [HR], 0.91 [95% CI, 0.88-0.94]; number needed to treat [NNT] = 40) and a 6% lower risk compared with those receiving fluticasone propionate–salmeterol (HR, 0.94 [95% CI, 0.89-0.98]; NNT = 40). The risk of moderate or severe COPD exacerbation was similar for patients receiving fluticasone propionate–salmeterol and budesonide-formoterol (HR, 0.98 [95% CI, 0.95-1.01]). No differences were observed in the risk of pneumonia hospitalization across the 3 cohorts (fluticasone furoate–vilanterol vs budesonide-formoterol: HR, 1.03 [95% CI, 0.96-1.11]; fluticasone furoate–vilanterol vs fluticasone propionate–salmeterol: HR, 0.93 [95% CI, 0.85-1.03]; and fluticasone propionate–salmeterol vs budesonide-formoterol: HR, 1.04 [95% CI, 0.98-1.10]).

In this cohort study of new ICS-LABA users with COPD, once-daily dry powder fluticasone furoate–vilanterol inhalers were associated with slightly improved clinical outcomes compared with twice-daily metered-dose budesonide-formoterol inhalers and twice-daily dry powder fluticasone propionate–salmeterol inhalers. Further studies are needed to explore potential intraclass differences among inhalers used to treat COPD.